COVID-19 Pandemic: Impact on Healthcare in Missouri

Everyone will remember what they were doing when the reality of the COVID-19 pandemic hit home with the associated feelings of foreboding and panic.

At first, I felt like I was surfing at the crest of a wave having been in China toward the end of November, in Japan toward the end of January, and in northern California on February 29, 2020. I finally landed in St. Louis to the difficult decision. As I was the national president for the American Academy of Dermatology (AAD), I would have to cancel AAD’s annual meeting in Denver in mid-March with 20,000 attendees. During my forced two-week staycation, I went through the feelings of fear, panic, worry, helplessness, concern about the damage COVID-19 was wreaking across the world, and compassion for all the people dying and their grieving families.

I picked myself up from the floor and proceeded to learn everything I could about COVID-19 and set up an ad-hoc task force for AAD. The task force has been putting together recommendations and resources as to how we can take care of our patients safely during this time.

The MSMA has likewise collected resources as to how you can function in the brave new world we now live in. At msma.org you will find dozens of resources on the new waivers for doing telemedicine, infection control, conservation and proper use of PPE, educational modules on various aspects of COVID-19, and HHS, CDC, WHO, CMS, Missouri DHSS, AMA, ACP, ACEP, MHA, and Johns Hopkins recommendations and waivers. The MSMA has been highly active in advocacy for telehealth regulation waivers, civil immunity during the pandemic, financial support for physician practices, and expanded COVID-19 testing capability. We called on the governor to issue a shelter-in-place order early on, and asked that opening up be done in a carefully considered manner. To keep members updated on current issues, the Association arranged for ongoing conference calls between MSMA and the director of MoDHSS, Randall Williams, MD, who is also an MSMA member.

Most elective and “non-essential” procedures and in-person visits were deferred in Missouri based on CDC and CMS recommendations in order to preserve PPE, and free up equipment, ORs, hospital beds, ICUs and ventilators for an expected surge of COVID-19 cases (as was seen in Italy and New York City), and to prevent the spread of the virus in the healthcare setting. As Homeland Security considers all healthcare services to be essential, Missouri was never under a state order to not perform these procedures. Fortunately, due to the shelter-in-place order and social distancing in general, the surge never materialized. Missouri successfully “flattened the curve,” just like St. Louis did during the influenza pandemic one hundred years ago.

A dramatic effect of limiting visits and procedures to only the very essential ones across the state has been a 50–100% drop in office visits and hospital activity, putting many practices and hospitals, especially in the rural part of the state, on the verge of financial ruin. The federal government has stepped up with temporary help in the form of loans and grants through Coronavirus 1–4 legislation (the last two called CARES Act I and II). The state has also received some of the CARES Act funds to distribute to healthcare providers in Missouri. This is welcome temporary relief, but not sustainable. Based on CDC definitions, most elective procedures and regular doctor visits with appropriate precautions, are “low-risk” encounters. A trip to the supermarket, hardware store, or gas station may well be “riskier” than going to the doctor’s office or an outpatient surgery center, which are much better controlled environments.

Another concern of the healthcare system near shutdown is starting to become apparent. Patients are afraid to go to the hospital. There has been a dramatic drop of patients coming to the hospital for heart attacks and strokes. I do not think many us believe that those diseases have just miraculously disappeared. We are starting to see cases of patients with heart attacks dying or patients with strokes suffering irreversible damage due to delaying coming to the hospital for fear of getting COVID-19.

Are some of the excess deaths we are reading about due to undocumented COVID-19 or due to other conditions that were not treated due to fear of COVID-19? Patients are deferring (or are being asked by their doctors to defer) getting chemotherapy or radiation therapy for cancer. In dermatology, NCCN recommended deferring treatment of thin melanomas for months. What do we tell such a melanoma patient that later develops metastatic disease when they ask if the delay may have allowed the metastasis to develop?

The economic damage caused by the virus in the U.S., with record unemployment expected to reach more than 20%, is and will cause a lot of hardship, which will fall on those least able to afford it. The layoffs are concentrated in jobs at the lower end of the wage scale. The impact will be huge. Fortunately, our safety net will help tide most over. My bigger concern is with the developing world where there is little or no safety net. What will happen in those areas with massive unemployment? I would anticipate widespread starvation, civil unrest, and death from non-COVID-19 causes.

As I write this, Missouri is a couple of weeks past its peak of new cases, Governor Parsons has relaxed the shelter-in-place order allowing all businesses to reopen with appropriate social distancing and other safety precautions in place on May 4, 2020. Kansas City started reopening on May 15 and St. Louis County and City May 18. All healthcare services can now be offered. Hopefully, it is not too late for our rural hospitals and clinics. For a successful restart, patients and staff must feel reassured that the clinic/hospital is taking reasonable precautions to keep everyone safe.

MSMA Council Chair George Hubbell, MD, delivers lunch to Amy Hamacher at Capital Regtion Medical Center.

The AMA and many other professional societies have posted “restarting your practice” documents to do just that. In our office, patients and staff are screened, both patients and staff wear masks, all doors are open, social distancing is enforced, patients wait in their car until they are called, they don’t bring companions with them, surfaces are constantly cleaned, etc. I have found that patients really appreciate the steps we are taking to keep them safe and that we are there to take care of their medical needs. By having a detailed, written COVID-19 pandemic preparedness plan in place, we have been able to bring back staff who were leery of working during these uncertain times.

Until there is a vaccine or some highly effective treatment, COVID-19 will be with us. We will have to get used to a new normal and learn to work and play in that environment for many months, if not years. I have worked through all my negative emotions by gaining knowledge and taking actions along with many of you. It is up to us, the physicians of Missouri, to convey that rational, yet optimistic outlook to our fellow Missourians. With sensible precautions and our American ingenuity, we will persevere and thrive again.